Wait lists at the VA may be a sign of things to come

Last year, several scandals unfolded involving the Veterans Health Administration. Close to home, the Fort Collins VA hospital falsified its wait times for clinic appointments. To meet the VA goal of clinic appointments within 14 days, the hospital instructed its clerks to “cook the books,” falsifying appointment records to give the illusion that the vets were being seen in a timely manner.

Farther away in Phoenix, the local VA hospital had two separate wait lists for clinic appointments and surgeries. One was the public wait list where everyone received timely appointments. The other was a secret wait list where veterans would wait a year or longer for treatment and where at least 40 veterans died waiting for appointments.

The VA system is the largest integrated health care system in the United States. It consists of 150 medical centers, 1,400 outpatient clinics, and 53,000 health care providers. This is a model of “one stop shopping” health care delivery where all providers are employed by the VA and all care is integrated under one umbrella, all at no cost to the patient.

This also represents the “holy grail” of single-payer universal health care championed by presidential candidate Bernie Sanders and President Obama. Are the high costs, confusion, and chaos of Obamacare paving the way for a VA-like system for the entire country?

If so, how are such systems working out elsewhere in the world? First let’s look at the British National Health Service where the government promises specialty care “within a maximum of 18 weeks from referral unless it’s clinically appropriate that you wait longer.” Suppose your headache or double vision is due to a brain tumor rather than a migraine? Or your belly pain is due to cancer rather than acid reflux? That four and a half month delay might mean the difference between life and death. It might be “clinically appropriate” to wait a year or longer for a hip or knee replacement since it’s not a life threatening condition, merely painful and inconvenient.

What happens when the wait list becomes too long? The VA approach is to simply hide the longer wait list and pretend it doesn’t exist. New Zealand took a more direct approach. Their government promised its residents elective surgery within six months of referral. When the wait list grew too long, they simply removed 35,000 patients from the wait list, sending them back to their GP. If the GP could have solved their patient’s problem, they would not have referred them for specialist care at the public hospital. Instead the patient must begin the referral process all over again.

Not mentioned is the obvious alternative, paying out of pocket for care in the parallel private system that exists in both countries. For those with the means to purchase private health insurance or simply write a check, high-quality care is available immediately. But this is not the “universal coverage” that Bernie Sanders is talking about.

The reality is that health care has a finite supply and infinite demand, meaning that some form of rationing will be needed. This is worthy of a societal debate. However care is rationed, there will be winners and losers, some getting all that they need and others being shortchanged.

The question is whether consumers of health care will self-ration based on cost and other market forces or whether our all knowing and benevolent government will decide for us. If the government is the arbiter of who gets what, expect the VA stories to become commonplace.

Brian C. Joondeph is an ophthalmologist and can be reached on Twitter @retinaldoctor. This article originally appeared in the Villager.

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Wait lists at the VA may be a sign of things to come 12 comments

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Patient Kit

There’s no doubt that wait times are shorter if millions of Americans have no access. Millions of Americans are “self-rationing” right now based on cost and severely limited personal funds. Limited healthcare resources available? Not enough to go around? Make it all direct pay and only those who can personally afford it get medical care. Short wait times for anyone with money. No wait times (or medical care) for those without money. Problem solved.

Thomas D Guastavino

And your solution is…..?

lurking for answers

“Make it all direct pay and only those who can personally afford it get medical care. Short wait times for anyone with money. No wait times (or medical care) for those without money. Problem solved.”

I completely read this wrong and it made an enormous amount of sense. Here is what I thought I read:

Make it ALL direct pay, (meaning direct pay primary care) those who can personally afford it get medical care. Short wait times. No wait times (and medical care) for those without money….because they would receive subsidies to pay for direct care medical practice of their choice. Problem solved…at least for the vast majority.

Patient Kit

A few thoughts and questions:

(1). How would subsidies to pay for direct care work? It would have to be legislated and guaranteed federally, not state by state like the current implementation of the ACA and Medicaid expansion where we are seeing some states trying to make it work and other states trying to make it fail. Would this apply only to primary care? What about specialists? Who pays for them?

(2). If we had subsidized direct primary care, a huge amount of Americans would need those subsidized: all of the people currently covered by Medicaid and Medicare, plus the more than 50% of currently working Americans between the ages of 26-64 who gross less than $30,000 annually. Are you okay with subsidizing that many Americans?

(3). If all Americans have access to primary care via direct pay, subsidized or not, how does that solve the shortage of primary care docs and long wait times? Wouldn’t we still have longer wait times if everyone has access? How does direct pay change the supply and demand ratio and wait times?

(4). It just feels like I’m hearing over and over, in various ways, people who currently have access to good medical care worrying about what they’ll lose if everyone has access. And that sounds like keeping what they have hinges on denying access to all.

PCPMD

For an article citing the massive failures of a government-run medical organization, your reply is particularly ironic. So if the government subsidized the care of everyone else the way it subsidizes the care of veterans, everyone would be on a year-plus wait-list, is what you’re implying?

Patient Kit

All I’m really saying is that for the millions of Americans with no access to medical care, a longer wait sounds comparatively better than what they have now (No access = no wait; therefore, no wait isn’t always a good thing).

Seneca

The author is 100% correct that the problem of supply and demand is affecting the entire U.S. with ever increasing wait times for non-urgent appointments. No relief seems to be on the horizon. The average age of the medical staff at my small community hospital is in the mid 50’s now and, unlike in the past, many physicians who did primarily evaluation and management can’t wait to get out as soon as their house is paid off and the kids are educated. In a not so distant era, many internists worked well into their 70’s–that is a rare occurrence now. In many places, a patient can get a nuclear stress test tomorrow but must wait weeks to months if they want a primary care doctor. Even the NP’s and PA’s are seeing the greener economic grass in specialty care.

So what is the answer? There is no simple sound bite. Less hassles and more money would be a good start, but even then the spigot takes over a decade to pump out more physicians. I fear the recent machinations of health care primarily done by the government are going to result in third world like care where wealthy people pay for whatever they want and the rest take their chances in the government clinics. Unexpected consequences indeed.

PCPMD

having traveled fairly extensively, I completely agree with you. Multiple aspects of a particular culture affect their satisfaction with their healthcare system. Chief among these include:

1) The cultural expectations of what the healthcare system is for, it’s limitations

2) What a “reasonable” wait time is for access to primary care, sub-specialty care, and advanced technologies

3) People’s perspective on mortality, and the instabilities of aging and dying

4) People’s expectations of supportive care from friends and family, and the broader safety-net that society and their community provide

These very important variables that affect the cost and structure of the healthcare system in any given country. For people to expect a European type healthcare system (at European type costs), we would need to embrace European ethos with regards to these broader cultural issues.

I.e. Socialized medicine may work for a socialist society, but that is not the society we have, nor the one most Americans want. A European style healthcare system would be abhorrently expensive, and utterly unacceptable to an American style public (especially the part of the public that will have to pay for it).

PW

What Americans seem to want is the “no cost” of socialized medicine, but with the high “quality”, convenience, choice and access of capitalist medicine.

Dorothygreen

Such wait lists are reversible and but will not decrease because the US does not have a bona fide health care system. Rather, we have fragmented, profit driven sickness services. And a chronically sick population.

We need to reform BOTH our health care and our Foodways in order to reverse US decline in education, economic freedom, as well as health indicators. As the richest country we are shamefully low on all these and more indicators

I have only found one person on KevinMD who blogs that the Swiss model of health care is the best choice for the US. I believe if physicians were familiar with it, they would have a group larger than the physician group for single payer.

Bernie Sanders believe the single payer model can work in the US. It can’t. Hillary Clinton understands single payer is not the best model but won’t say what is – perhaps it’s the contributor effect – insurance, pharma, unions. The Republican candidates won’t accept it as there is no room for government- private cooperative solutions – no matter how fair or even if it limits government involvement. If there were Republican’s who could see the value of this model as being less government involvement – they might embrace it and be more appealing.

The Swiss mode is an insurance model. Everyone must have health insurance for basic services. For-profit is outlawed for basic services. Insurance companies can sell supplemental services – this is where the competition occurs and 70% of the population has some to all supplemental health insurance because it is affordable, there is choice and it is al carte. The other 30% choose managed care or are low income and subsidized by the government for insurance premiums. This is what the Swiss “we the people” voted for. There is no such thing as Medicaid – the poster child of US inequality. Medicare and the VA are US anomalies and might remain in some other form or be phased out over time.

All players negotiate with the central government, this even includes insurance companies for basic services premiums. Subsequent to this, the insurance companies administer the program at the Canton level and negotiate with physicians and hospitals using the centrally negotiated prices. The negotiated floor of not for profit services and a high ceiling of for profit services, accommodates both rich and poor. There is no place for direct pay to physicians and there is not the fraud and abuse that plagues the US. Physicians’ average compensation similar to US. And the Swiss total annual costs are about half that of the US.

A striking difference between Switzerland and the US, is the obesity rate- an indicator of a country’s health. The US is now about 38% (CDC data) whereas in Switzerland it is under 10%. This makes a huge difference in health care services usage. To that end, it is time for the US to tax all added sugar and refined grains just as tobacco was. The substances are now the leading risk factor in chronic preventable diseases.

When this model is presented, before the naysayers open their mouths and say “it can’t be done, there is no political will,” tell them they should not interrupt those who are doing or trying to get it done.”

vicnicholls

Informative post. Thank you.

Patient Kit

From what you (and Margalit Gur-Arie) have said, the Swiss system sounds good to me. Whether the Swiss system, a single payer system or something else, what I care about is that all Americans have access to good affordable healthcare. I have lived through being diagnosed with cancer while uninsured and nobody should have to deal with that kind of fear.